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Eid JJ, Jyot A, Macedo FI, Sabir M, Mittal VK. Robotic Cholecystectomy Is a Safe Educational Alternative to Laparoscopic Cholecystectomy During General Surgical Training: A Pilot Study. J Surg Educ 2020; 77:1266-1270. [PMID: 32217123 DOI: 10.1016/j.jsurg.2020.02.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/20/2020] [Accepted: 02/23/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE The role of robotic surgery in general surgery (GS) continues to expand. Several programs have integrated robotic-based simulators and models into surgical education; however, residents' robotic experience in the operating room is currently limited. We sought to assess the safety and feasibility of robotic cholecystectomy (RC) when independently performed by GS chief residents. METHODS From June 2016 to October 2018, RC and laparoscopic cholecystectomies (LC) performed independently by chief residents on a resident staff surgical service were prospectively included. Patient demographics, intraoperative variables, and postoperative complications were analyzed and compared between both cohorts. RESULTS A total of 20 RC and 70 LC were included. Patient characteristics, indications for surgery, and comorbidities were similar in both groups. RC was more likely to be performed electively (95% vs. 17.1%, p < 0.001). No difference in operative time, estimated blood loss, intraoperative bile duct injury, or conversion to open was observed. Patients undergoing LC had an overall longer mean length of hospital stay (2.7 days ± 2.1 vs. 0.8 days ± 0.4, p < 0.001); however, length of hospital stay was similar between RC and LC performed electively (p = 0.946). No difference in postoperative complications and 30-day readmission was observed. CONCLUSIONS RC can be safely and independently performed by GS residents with similar outcomes as LC. Efforts should be directed toward creating a platform to bridge competent simulator skills into safe performance in the operating suite. The integration of robotic training into the core GS curriculum should be encouraged.
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Affiliation(s)
- Joseph J Eid
- Department of Surgery, Ascension Providence Hospital, Michigan State University College of Human Medicine-Southeast Campus, Southfield, Michigan.
| | - Apram Jyot
- Department of Surgery, Ascension Providence Hospital, Michigan State University College of Human Medicine-Southeast Campus, Southfield, Michigan
| | - Francisco Igor Macedo
- Department of Surgery, Ascension Providence Hospital, Michigan State University College of Human Medicine-Southeast Campus, Southfield, Michigan
| | - Mubashir Sabir
- Department of Surgery, Ascension Providence Hospital, Michigan State University College of Human Medicine-Southeast Campus, Southfield, Michigan
| | - Vijay K Mittal
- Department of Surgery, Ascension Providence Hospital, Michigan State University College of Human Medicine-Southeast Campus, Southfield, Michigan
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2
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Azab B, Macedo FI, Chang D, Ripat C, Franceschi D, Livingstone AS, Yakoub D. The Impact of Prolonged Chemotherapy to Surgery Interval and Neoadjuvant Radiotherapy on Pathological Complete Response and Overall Survival in Pancreatic Cancer Patients. Clin Med Insights Oncol 2020; 14:1179554920919402. [PMID: 32669884 PMCID: PMC7336830 DOI: 10.1177/1179554920919402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 03/04/2020] [Indexed: 01/15/2023]
Abstract
Background: We aimed to study the impact of neoadjuvant chemotherapy to surgery (NCT-S)
interval and neoadjuvant radiotherapy (NRT) on pathological complete
response (pCR) and overall survival (OS) in pancreatic cancer (pancreatic
ductal adenocarcinoma [PDAC]). Methods: National Cancer Data Base (NCDB)–pancreatectomy patients who underwent
NCT/NRT were included. The NCT-S interval was divided into time quintiles in
weeks: 8 to 11, 12 to 14, 15 to 19, 20 to 29, and >29 weeks. Results: A total of 2093 patients with NCT were included with median follow-up of
74 months and 71% NRT. The pCR rate was 2.1% with higher median OS compared
with non-pCR (41 vs 19 months, P = .03). The pCR rate
increased with longer NCT-S interval (quintiles: 1%, 1.6%, 1.7%, 3%, and 6%,
P < .001, respectively). In logistic regression, NRT
(odds ratio [OR] = 2.5, 95% confidence interval [CI]: 1.1-6.1,
P = .03) and NCT-S >29 weeks (OR = 6.1, 95%
CI = 2.02-18.50, P < .001) were predictive of increased
pCR. The prolonged NCT-S interval and pCR were independent predictors of OS,
whereas NRT was not. Conclusions: Longer NCT-S interval and pCR were independent predictors of improved OS in
patients with PDAC. The NRT predicted increased pCR but not OS.
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Affiliation(s)
- Basem Azab
- Surgical Oncology, Sentara Healthcare, Sentara CarePlex Hospital, Hampton, VA, USA
| | - Francisco Igor Macedo
- Surgical Oncology, DeWitt Daughtry Family Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David Chang
- Virginia Oncology Associate, Hampton, VA, USA
| | - Caroline Ripat
- Surgical Oncology, DeWitt Daughtry Family Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Dido Franceschi
- Surgical Oncology, DeWitt Daughtry Family Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Alan S Livingstone
- Surgical Oncology, DeWitt Daughtry Family Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Danny Yakoub
- Surgical Oncology, DeWitt Daughtry Family Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
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3
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Ibrahim C, Parra N, Macedo FI, Yakoub D. Is hepatic resection better than transarterial chemoembolization in hepatocellular carcinoma with portal vein tumor thrombosis? J Gastrointest Oncol 2020; 10:1064-1072. [PMID: 31949923 DOI: 10.21037/jgo.2019.09.07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background The management of hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) remains controversial. We compared the outcomes of hepatic resection (HR) and transarterial chemoembolization (TACE). Methods Comprehensive online databases search was performed. Comparative studies measuring survival in HCC patients with PVTT undergoing HR versus TACE were included. Pooled risk ratios with corresponding 95% confidence intervals (CI) were calculated for overall survival (OS) at 1, 3, and 5 years. Study quality and heterogeneity was assessed. Results Six studies comprising 1,320 patients were included. HR was done in 526 (39.8%) patients and TACE in 794 (60.2%) patients. Meta-analysis of all included studies showed improved OS in HR compared to TACE patients at 1-year (OR: 1.49, 95% CI: 1.16-1.92, P=0.002), 3-year (OR: 3.33, 95% CI: 1.55-7.12, P=0.002) and 5-year (OR: 3.91, 95% CI: 1.42-10.77, P=0.008). Survival benefit conferred by HR was 7-33 months. This benefit was mostly noted in tumors with PVTT types I and II and those with single lesions. Age, ECOG status, and STROBE score did not contribute to differences in survival. Conclusions Long-term survival outcomes of HCC with PVTT are superior in patients undergoing hepatectomy compared to TACE. Further experience with randomized clinical trials may be warranted to confirm these findings.
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Affiliation(s)
- Catrine Ibrahim
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Natalia Parra
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Francisco Igor Macedo
- North Florida Regional Medical Center, University of Central Florida College of Medicine, Gainesville, FL, USA
| | - Danny Yakoub
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
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4
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Eid JJ, Reiley MI, Miciura AL, Macedo FI, Negussie E, Mittal VK. Interpretation of Basic Clinical Images: How Are Surgical Residents Performing Compared to Other Trainees? J Surg Educ 2019; 76:1500-1505. [PMID: 31080122 DOI: 10.1016/j.jsurg.2019.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 03/29/2019] [Accepted: 04/21/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND During medical training students, residents, and fellows learn how to accurately interpret basic radiographic images. This skill is mostly utilized by physicians in the acute and critical care settings. It is unclear whether surgical residents' interpretation skills differ from that of other trainees. METHODS A 30-question online quiz was developed to evaluate trainees' skills in interpreting images using various radiologic modalities. The participating cohort included (1) medical students (MS), (2) general surgery residents (GST), internal medicine residents and fellows (IMT), and radiology trainees (RT). The impact of residency specialty and level of training on performance was evaluated. RESULTS A total of 69 postgraduate trainees and 19 MS enrolled in the online quiz. The average score was 67.6% (±16.6). GST scored higher than IMT (74.2% ± 10.7% vs. 67.9% ± 11.3%, p = 0.038); however, they were equally proficient to RT. MS had the lowest interpretation accuracy rates compared to postgraduate trainees (57.4% ± 16.8%, p < 0.001). On different radiographic modalities, junior GST performance was comparable to MS, JR-IMT, and Junior Radiology Trainees (JR-RT). On computed tomography (CT) body, GST (83.1% ± 15.7%) scored higher than IMT (70.3% ± 17.7%, p = 0.026) and MS (61.7% ± 23.4%, p < 0.001). Similar findings were demonstrated on ultrasound modality. A difference in performance was not evident for X-rays, CT head, and tubes/lines localization images. CONCLUSIONS GST were able to correctly interpret 74.2% of basic clinical images. Although superior in the evaluation of pathologies seen on CT body and ultrasound, GST have comparable performance to other trainees in X-rays, tube/line localization images, and CT head. Integration of radiology education in surgical training may enhance performance and potentially improve patient care.
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Affiliation(s)
- Joseph J Eid
- Department of Surgery, Providence-Providence Park Hospital, Michigan State University College of Human Medicine, Southfield, Michigan.
| | - Maia I Reiley
- Department of Surgery, Providence-Providence Park Hospital, Michigan State University College of Human Medicine, Southfield, Michigan
| | - Angela L Miciura
- Michigan State University College of Human Medicine, East Lansing, Michigan
| | - Francisco Igor Macedo
- Department of Surgery, Providence-Providence Park Hospital, Michigan State University College of Human Medicine, Southfield, Michigan
| | - Edsa Negussie
- Department of Radiology, Providence-Providence Park Hospitals, Michigan State University College of Human Medicine, Southfield, Michigan
| | - Vijay K Mittal
- Department of Surgery, Providence-Providence Park Hospital, Michigan State University College of Human Medicine, Southfield, Michigan
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5
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Azab B, Macedo FI, Picado O, Ripat C, Franceschi D, Livingstone AS, Yakoub D. The value of lymphadenectomy in esophageal cancer after neoadjuvant chemoradiation. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.4_suppl.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
79 Background: There are conflicting reports on the value of the extent of post neoadjuvant chemoradiation (NCRT) lymphadenectomy (LND) in locally advanced esophageal adenocarcinoma (E-ADC) and squamous cell carcinoma (E-SCC). We sought to study the impact of LND variables [positive and total lymph node (LN) number and LN ratio (LNR)] on oncological outcomes in these patients. Methods: The National Cancer Data Base 2004-2014 was queried for patients with NCRT followed by esophagectomy. The median examined LN number was used to divide the patients into a higher (> 12) and lower (≤ 12) LND groups. The primary outcome was overall survival (OS) and secondary outcomes were 30- and 90-day postoperative mortality. Results: A total 4708 patients were included. The median of positive, negative LN, and LNR were and (0, 11, 0%). The median and 5-year OS for higher LND group were higher than the lower LND group (39 vs. 32 months, 38% vs. 34%), p < 0.0001. OS was not significantly different among E-SCC subset or among those who achieved pathological complete response (pCR). The higher LND group had better 30- and 90-day postoperative mortality rates (61/2335 = 2.6%, 141/2308 = 6.1%) than lower LND group (86/2262 = 3.8%, 184/2251 = 8.2%), p = 0.01 and 0.001, respectively . In multivariate Cox regression analysis, higher LND group (HR 0.88, 95% CI 0.81-0.96, p = 0.004) and LNR (per 10% increase: 1.11, 95% CI 1.09-1.13, p < 0.0001) were significant predictor of OS. Conclusions: The LND (> 12 examined LN) remains as a crucial treatment goal after NCRT with potential survival benefit, especially among E-ADC and those did not achieve pCR.
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Affiliation(s)
| | | | - Omar Picado
- Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, FL
| | - Caroline Ripat
- University of Miami Miller School of Medicine, Miami, FL
| | - Dido Franceschi
- Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, FL
| | - Alan S Livingstone
- Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, FL
| | - Danny Yakoub
- Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, FL
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6
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Azab B, Macedo FI, Picado O, Franceschi D, Livingstone AS, Yakoub D. The impact of neoadjuvant chemoradiation versus chemotherapy on short and long-term outcomes among gastric carcinoma patients. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.4_suppl.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
78 Background: There is little consensus on the use of neoadjuvant chemoradiation (NCRT) versus neoadjuvant chemotherapy (NCT) in gastric carcinoma (GC) patients. We sought to compare the outcomes of these two approaches in a large national data base. Methods: National Cancer Data Base PUF (2004-2014) of GC patients who underwent NCRT/NCT followed by resection were included. Primary outcome was overall survival (OS), secondary outcomes were pathological complete response (pCR), R0 resection and postoperative mortality. Results: A total of 4204 GC patients with NCT were included, 62% of them had additional neoadjuvant radiotherapy (NRT). NCRT had higher pCR and R0 rates [551/2613 (21%), 2314/2561 (90%)] than NCT group [148/1573 (9%), 1242/1543 (80%)], p < 0.0001. Multivariate logistic regression showed similar higher odds of pCR (OR 2.8, 95% CI 1.65-4.60, p < 0.0001) and R0 (OR 1.5, 95% CI 1.14-1.99, p = 0.004) among NCRT versus NCT. There was no significant difference in length of hospital stay, 30-day readmission rate, 30- and 90-day postoperative mortality. Median, 3- and 5-year OS for NCRT versus NCT were: (20.4 months, 24% and 11%) versus (18.3 months, 19% and 6%), p < 0.001. Univariate cox regression analysis showed superior OS with NRT (HR 0.9, 95% CI 0.80-0.91, p < 0.001). After adjusting for confounding variables, pCR (HR 0.2, 95% CI 0.18-0.24, p < 0.001) and R0 (HR 0.7, 95% CI 0.61-0.75, p < 0.001) had better OS, while NRT was not. Conclusions: NRT improved pCR and R0 rates in GC without increase in surgical morbidity/mortality. The long-term OS benefit of NRT is likely secondary to higher pCR and R0 resection.
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Affiliation(s)
| | | | - Omar Picado
- Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, FL
| | - Dido Franceschi
- Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, FL
| | - Alan S Livingstone
- Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, FL
| | - Danny Yakoub
- Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, FL
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7
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Macedo FI, Fayne RA, Azab B, Yakoub D, Möller MG. The Role of Completion Lymphadenectomy in Positive Regional Lymph Nodes in Melanoma: A Meta-analysis. J Surg Res 2018; 236:83-91. [PMID: 30694783 DOI: 10.1016/j.jss.2018.11.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 05/03/2018] [Accepted: 11/09/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND The optimal management of melanoma with positive sentinel lymph node (SLN) remains unclear. Completion lymph node dissection (CLND) only yields additional positive non-SLN in 20% of cases and its benefits on survival remains debatable. METHODS An online database search of Medline was performed; key bibliographies were reviewed. Studies comparing outcomes after CLND versus observation were included. Odds ratios (ORs) with the corresponding 95% confidence intervals (CIs) by random fixed effects models of pooled data were calculated. The primary endpoints were disease-free survival (DFS), melanoma-specific survival (MSS), and overall survival (OS). RESULTS Search strategy yielded 117 publications. Twelve studies were selected for inclusion, comprising 7966 SLN-positive patients. Among these patients, 5306 (66.6%) subjects underwent CLND and 2660 (33.4%) patients were observed. Median Breslow thickness and ulceration were similar between groups (2.8 ± 0.6 mm versus 2.5 ± 0.8 mm, P = 0.721; and 38.8% versus 37.2%, P = 0.136, CLND versus observation, respectively). CLND was associated with statistically significant improved 3-y (71.0% versus 66.2%, OR 0.82, 95% CI 0.69-0.97, P = 0.02) and 5-y DFS (48.3% versus 47.8%, OR 0.75, 95% CI 0.59-0.96, P = 0.02) compared with observation. However, no difference was demonstrated in 3-y MSS (83.7% versus 84.7%, OR 1.09, 95% CI 0.88-1.35, P = 0.41), 5-y MSS (68.4% versus 69.8%, OR 1.02, 95% CI 0.88-1.19, P = 0.78), or OS (68.2% versus 78.9%, OR 0.93, 95% CI 0.55-1.57, P = 0.78). CONCLUSIONS Based on this large-scale analysis, CLND improved both 3- and 5-y DFS, possibly because of increased rates of local control; however, this did not translate in improved MSS or OS. Efforts toward the identification of molecular markers associated with poor outcomes in SLN-positive patients who undergo observation are warranted.
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Affiliation(s)
- Francisco Igor Macedo
- Division of Surgical Oncology, Jackson Memorial Hospital and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida.
| | - Rachel A Fayne
- Division of Surgical Oncology, Jackson Memorial Hospital and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Basem Azab
- Division of Surgical Oncology, Jackson Memorial Hospital and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Danny Yakoub
- Division of Surgical Oncology, Jackson Memorial Hospital and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Mecker G Möller
- Division of Surgical Oncology, Jackson Memorial Hospital and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
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8
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Macedo FI, Salerno TA. The value of long-term postoperative quality of life and patient-centered decision-making: What is at stake? J Thorac Cardiovasc Surg 2018; 156:2192-2193. [DOI: 10.1016/j.jtcvs.2018.05.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 05/19/2018] [Accepted: 05/21/2018] [Indexed: 11/28/2022]
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9
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Azab B, Macedo FI, Cass SH, Ripat C, Razi SS, Picado O, Franceschi D, Livingstone AS, Yakoub D. A large national comparative study of clinicopathological features and long-term survivals between esophageal gastrointestinal stromal tumor and leiomyosarcoma. Am J Surg 2018; 218:323-328. [PMID: 30471808 DOI: 10.1016/j.amjsurg.2018.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 10/25/2018] [Accepted: 10/29/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Esophageal gastrointestinal stromal tumors (E-GIST) and leiomyosarcoma (E-LMS) are rare tumors. Previous studies are limited to small number of patients. We sought to study these two tumors using a large national database. METHODS The National Cancer Data Base 2004-2014 was queried for patients with E-GIST and E-LMS. The primary outcome was overall survival (OS). Univariate and multivariable Cox regression models were used to investigate OS predictors. RESULTS We found 141 E-GIST and 38 E-LMS patients, with esophagectomy and systemic treatment rate of 55% and 49% for E-GIST and 50% and 26% for E-LMS. The 5-year OS of E-GIST and E-LMS were 62% and 23%, respectively, p < 0.001. In multivariable analysis, young age, tumor <10 cm, esophagectomy, and E-GIST were associated with superior OS. There was a higher median and mean OS with neoadjuvant vs. upfront surgery for E-GIST group (98 and 111 vs 79 and 80 months). CONCLUSION E E-GIST has superior OS compared to E-LMS. Esophagectomy is the cornerstone treatment modality. Further studies are needed to evaluate the role of neoadjuvant therapy in E-GIST patients.
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Affiliation(s)
- Basem Azab
- Surgical Oncology, Sentara Careplex Hospital, Sentara Healthcare System, Hampton, VA, USA.
| | - Francisco Igor Macedo
- Surgical Oncology Division, Department of Surgery, University of Miami, Miami, FL, USA
| | - Samuel H Cass
- Surgical Oncology Division, Department of Surgery, University of Miami, Miami, FL, USA
| | - Caroline Ripat
- Surgical Oncology Division, Department of Surgery, University of Miami, Miami, FL, USA
| | - Syed S Razi
- Surgical Oncology Division, Department of Surgery, University of Miami, Miami, FL, USA
| | - Omar Picado
- Surgical Oncology Division, Department of Surgery, University of Miami, Miami, FL, USA
| | - Dido Franceschi
- Surgical Oncology Division, Department of Surgery, University of Miami, Miami, FL, USA
| | - Alan S Livingstone
- Surgical Oncology Division, Department of Surgery, University of Miami, Miami, FL, USA
| | - Danny Yakoub
- Surgical Oncology Division, Department of Surgery, University of Miami, Miami, FL, USA
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10
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Azab B, Amundson JR, Picado O, Ripat C, Macedo FI, Franceschi D, Livingstone AS, Yakoub D. Impact of Chemoradiation-to-Surgery Interval on Pathological Complete Response and Short- and Long-Term Overall Survival in Esophageal Cancer Patients. Ann Surg Oncol 2018; 26:861-868. [DOI: 10.1245/s10434-018-6897-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Indexed: 12/25/2022]
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11
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Cooper N, Roshdy M, Sciarretta JD, Kaufmann C, Duncan S, Davis J, Macedo FI. Multidisciplinary team approach in the management of popliteal artery injury. J Multidiscip Healthc 2018; 11:399-403. [PMID: 30214221 PMCID: PMC6118273 DOI: 10.2147/jmdh.s151498] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Popliteal artery injuries (PAIs) remain a challenging entity and carry the greatest risk of limb loss among traumatic lower extremity vascular injuries. Operative management of traumatic popliteal vascular injuries continues to evolve. Improved diagnostic imaging and the introduction of endovascular techniques offered alternative modalities to traditional surgical management. Despite major efforts in establishing protocols and guidelines in the management of vascular trauma, optimal strategies of traumatic PAIs are still under investigation. Herein, we discussed the role of multidisciplinary team, involving trauma and endovascular surgeons, emergency department personnel, and interventional radiologists in the management of complex PAIs.
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Affiliation(s)
- Neal Cooper
- Department of Surgery, Grand Strand Health, Myrtle Beach, SC, USA,
| | - Mazen Roshdy
- Department of Surgery, Grand Strand Health, Myrtle Beach, SC, USA,
| | | | | | - Scott Duncan
- Department of Surgery, Grand Strand Health, Myrtle Beach, SC, USA,
| | - John Davis
- Department of Surgery, Grand Strand Health, Myrtle Beach, SC, USA,
| | - Francisco Igor Macedo
- Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
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12
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Picado O, Dygert L, Macedo FI, Franceschi D, Sleeman D, Livingstone AS, Merchant N, Yakoub D. The Role of Surgical Resection for Stage IV Gastric Cancer With Synchronous Hepatic Metastasis. J Surg Res 2018; 232:422-429. [PMID: 30463751 DOI: 10.1016/j.jss.2018.06.067] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/23/2018] [Accepted: 06/20/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND With improved responses to chemotherapy and targeted treatments, the role of surgery in metastatic gastric cancer (MGC) to the liver needs to be revisited. We sought to examine whether surgical resection is associated with improvement of long-term survival. METHODS The National Cancer Database was queried for MGC to the liver (2010-2014). Survival analysis was performed to compare the effect of gastrectomy and perioperative chemotherapy (G-CT) to palliative chemotherapy (PCT) alone. RESULTS We identified 3175 patients with MGC to the liver. Most patients (94%, n = 2979) were treated with PCT, whereas 6% (n = 196 patients) underwent G-CT. Overall survival improved in patients treated with G-CT compared to PCT alone (16 versus 9.7 mo, P < 0.001). In patients undergoing G-CT, neoadjuvant chemotherapy was associated with increased overall survival compared to adjuvant chemotherapy (18.9 versus 14.8 mo, P = 0.011). Hazards of death significantly decreased with gastrectomy (hazard ratio [HR]: 0.53, 95% confidence interval [CI]: 0.44-0.63, P < 0.001). Negative prognostic factors included advanced age (HR: 1.10, 95% CI: 1.06-1.14, P < 0.001), treatment at nonacademic institution (HR: 1.23, 95% CI: 1.13-1.33, P < 0.001), and poorly differentiated grade (HR: 1.54, 95% CI: 1.17-2.03, P < 0.001). CONCLUSIONS G-CT is associated with improved survival in patients with gastric cancer and synchronous liver metastasis. Further experience with well-designed prospective trials may be warranted to confirm these findings.
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Affiliation(s)
- Omar Picado
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Levi Dygert
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Francisco Igor Macedo
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Dido Franceschi
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Danny Sleeman
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Alan S Livingstone
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Nipun Merchant
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Danny Yakoub
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, Florida.
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13
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de Mesquita Neto JWB, Macedo FI, Liu Y, Yiengpruksawan A. Fully robotic total pancreatectomy: technical aspects and outcomes. J Robot Surg 2018; 13:77-82. [PMID: 29713931 DOI: 10.1007/s11701-018-0818-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 04/23/2018] [Indexed: 10/17/2022]
Abstract
Robotic total pancreatectomy (RTP) is a novel surgical approach currently performed by a select group of skilled surgeons. As robotic approaches to pancreatic surgery increase worldwide, rates of RTP are expected to increase. However, the standard technique is still evolving and several technical problems still require evaluation. Here, we describe our approach in a stepwise fashion and discuss solutions to overcome technical difficulties.
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Affiliation(s)
| | - Francisco Igor Macedo
- Division of Surgical Oncology, Jackson Memorial Hospital and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Detroit, MI, USA
| | - Yang Liu
- Department of Surgery, University Health Center, Wayne State University School of Medicine, 6C, 4201 St. Antoine, Detroit, MI, 48201, USA
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14
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Macedo FI, Salerno TA. Measuring value in health care: What price are surgeons going to pay? J Thorac Cardiovasc Surg 2018; 156:1449-1450. [PMID: 29751958 DOI: 10.1016/j.jtcvs.2018.04.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Francisco Igor Macedo
- Dewitt-Daughtry Department of Surgery, Jackson Memorial Hospital and the University of Miami Miller School of Medicine, Miami, Fla
| | - Tomas A Salerno
- Division of Cardiothoracic Surgery and Jackson Memorial Hospital and the University of Miami Miller School of Medicine, Miami, Fla.
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15
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Azab B, Picado O, Ripat C, Macedo FI, Livingstone AS, Franceschi D, Yakoub D. The impact of the chemoradiation to surgery interval on pathological complete response: Short and long-term overall survival in esophageal cancer patients. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.4_suppl.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2 Background: The association of the interval between neoadjuvant chemo-radiation and surgery (CRT-S), and cancer outcomes in patients with esophageal cancer is not clear. We aimed to determine the relationship between CRT-S interval and pathological complete response rate (pCR), short and long overall survival (OS). Methods: Patients listed on the National Cancer Data Base from 2004 to 2013 were studied. We included patients with CRT followed by surgery in 15-90 days. All patients had reported pT, pN cancer stages and survival status. CRT-S interval was studied as continuous (weeks) and categorical variables (quintiles). Results: A total of 5181 patients were included; 81% were adenocarcinomas, 84% were males and mean age was 62 years. They were divided into CRT-S interval quintiles (15 to 37, 38 to 45, 46 to 53, 54 to 64 and 65 to 90 days) (n = 1016, 1063, 1081, 1083 and 938 patients), respectively. There was a significant increase of pCR rate across the CRT-S quintiles (18%, 21%, 24%, 25% and 29%, p < 0.001). This advantage persisted when CRT-S was measured as continuous variable in weeks (OR: 1.11, 95% CI = 1.078-1.143, p < 0.001). However, 90-day mortality significantly increased as CRT-S increased across quintiles (5.7%, 6.2%, 6.8%, 8.5% and 8.2%, p = 0.02) and through weeks (OR = 1.05, 95%CI = 1.005-1.106, p = 0.03). Mean OS across CRT-S quintiles was 59.2, 58.8, 55.4, 56.6 and 51.5 months, respectively. Multivariate Cox regression showed significantly worse OS per week increase in CRT-S interval (HR 1.02, 95% 1.003-1.037, p = 0.02), especially among the last quintile (CRT-S = 65-90 days: HR 1.2, 95% CI 1.04-1.32, p = 0.009). Those with no-pCR had worse OS as time to surgery increased (p < 0.001), while pCR group had similar OS across CTR-S intervals. Conclusions: Despite higher pCR rate as CRT-S interval increasing, surgery is preferred to be done in less than 65 days after CRT to avoid worse 90-day mortality and achieve better OS. Further randomized studies are needed to consolidate our findings.
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Affiliation(s)
| | - Omar Picado
- University of Miami Miller School of Medicine, Miami, FL
| | - Caroline Ripat
- University of Miami Miller School of Medicine, Miami, FL
| | | | | | - Dido Franceschi
- University of Miami Sylvester Comprehensive Cancer Center, Miami, FL
| | - Danny Yakoub
- University of Miami Sylvester Comprehensive Cancer Center/ Jackson Memorial Hospital, Miami, FL
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16
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Macedo FI, Eid JJ, Decker M, Herschman B, Negussie E, Mittal VK. Autogenous hepatic tissue transplantation into the omentum in a novel ectopic liver regeneration murine model. J Surg Res 2017; 223:215-223. [PMID: 29433876 DOI: 10.1016/j.jss.2017.11.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 09/20/2017] [Accepted: 11/10/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Liver regeneration involves hyperplasia and hypertrophy of hepatic cells. The capacity of macroscopic liver tissue to regenerate in ectopic sites is unknown. We aim to develop a novel in vivo model of ectopic liver survivability and regeneration and assess its functionality. METHODS Adult male Sprague-Dawley rats (n = 23) were divided into four groups: (1) single-stage (SS) group, wedge liver resection was performed, and the parenchyma was directly implanted into the omentum; (2) double-stage (DS) group, omentum pedicle was transposed over the left hepatic lobe followed by wedge liver resection along with omental flap; (3) Biogel + DS group, rats received intraperitoneal injection of inert polymer particles prior to DS; (4) Biogel + DS + portal vein ligation (PVL) group, Biogel + DS rats underwent subsequent PVL. Hepatobiliary iminodiacetic acid scintigraphy assessed bile excretion from ectopic hepatic implants. RESULTS Histologically, the scores of necrosis (P < 0.001) and fibrosis (P = 0.004) were significantly improved in rats undergoing DS procedure (groups 2, 3, and 4) compared with the SS group. Biogel rats (Biogel + DS and Biogel + DS + PVL) demonstrated statistically increased scores of bile duct neoformation (P = 0.002) compared to those without the particles (SS and DS). Scintigraphy demonstrated similar uptake of radiotracer by ectopic hepatic implants in groups 2, 3, and 4. CONCLUSIONS Omental transposition provided adequate microcirculation for proliferation of ectopic hepatic cells after liver resection. Inert polymers enhanced the regeneration by promoting differentiation of new bile ducts. The ectopic hepatic implants showed preserved function on scintigraphy. This model provides insights into the capacity of liver parenchyma to regenerate in ectopic sites and the potential as therapeutic target for cell therapy in end-stage liver disease.
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Affiliation(s)
- Francisco Igor Macedo
- Department of Surgery, Providence Hospital and Medical Centers, Michigan State University College of Human Medicine, Southfield, Michigan.
| | - Joseph J Eid
- Department of Surgery, Providence Hospital and Medical Centers, Michigan State University College of Human Medicine, Southfield, Michigan
| | - Milessa Decker
- Department of Surgery, Providence Hospital and Medical Centers, Michigan State University College of Human Medicine, Southfield, Michigan
| | - Barry Herschman
- Department of Pathology, Providence Hospital and Medical Centers, Michigan State University College of Human Medicine, Southfield, Michigan
| | - Edsa Negussie
- Department of Radiology, Providence Hospital and Medical Centers, Michigan State University College of Human Medicine, Southfield, Michigan
| | - Vijay K Mittal
- Department of Surgery, Providence Hospital and Medical Centers, Michigan State University College of Human Medicine, Southfield, Michigan
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17
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Eid JJ, Macedo FI, Mittal VK. Utilisation of radiology rotations in ACGME-accredited general surgery programmes. Postgrad Med J 2017; 93:587-591. [DOI: 10.1136/postgradmedj-2016-134549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 03/02/2017] [Accepted: 03/19/2017] [Indexed: 11/04/2022]
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Abstract
Cecal bascule is a rare cause of bowel obstruction in which a mobile cecum folds anteriorly and superiorly over the ascending colon. Herein, we present the first case of internal herniation of a cecal bascule into the lesser sac through the foramen of winslow, aiming at discussing radiological findings, differential diagnosis, and surgical management of this uncommon condition. A 75-year-old female presented to the emergency room with an 18-h history of sudden onset sharp, progressively worsening abdominal pain associated with vomiting. Physical exam revealed abdominal distention and epigastric tenderness while initial laboratory tests were unremarkable. Computed tomography of her abdomen and pelvis showed a loop of distended colon within lesser sac without signs of bowel ischemia or perforation. On exploratory laparotomy, a cecal bascule was found herniating into lesser sac via foramen of winslow. Upon reduction, the cecum appeared viable therefore a cecopexy was performed without bowel resection. Unlike cecal volvulus, cecal bascule consists of no axial rotation of the bowel with no mesenteric vascular compromise and therefore ischemia would only occur from intraluminal tension or extraluminal compression from the borders of foramen of winslow. The management of internal herniation of a cecal bascule is always surgical including anatomic resection or cecopexy.
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Macedo FI, Taggarshe D, Makarawo T, Herschman B, Jacobs MJ. Pancreatic intraepithelial neoplasia arising from an ectopic pancreas in the small bowel. Hepatobiliary Pancreat Dis Int 2014; 13:658-61. [PMID: 25475871 DOI: 10.1016/s1499-3872(14)60273-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Ectopic pancreatic tissue is relatively uncommon, and is characterized as pancreatic tissue with no contact with the normal pancreas, and with its own ductal system and blood supply. It is usually asymptomatic, and can be incidentally diagnosed by conventional imaging studies. METHOD A 69-year-old woman with a prior history of bilateral breast carcinoma presented with ectopic pancreatic intraepithelial neoplasia (PanIN) that was identified incidentally in the small bowel during an oncological resection of a synchronous primary pancreatic adenocarcinoma, and renal cell carcinoma. RESULTS The patient underwent subtotal pancreatectomy with splenectomy, regional lymphadenectomy, radical left nephrectomy, and small bowel resection with primary anastomosis of ectopic PanIN-2. She had an uneventful hospitalization and was discharged home on postoperative day 7. CONCLUSIONS The occurrence of ectopic PanIN is extremely unusual with only few cases previously reported in the literature. The need for negative margins after surgical resection of ectopic PanIN lesions remains controversial.
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Affiliation(s)
- Francisco Igor Macedo
- Department of General Surgery, Providence Hospital and Medical Centers, Southfield, MI 48075, USA.
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20
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Macedo FI. Current management of noninfectious hepatic cystic lesions: A review of the literature. World J Hepatol 2013; 5:462-469. [PMID: 24073297 PMCID: PMC3782683 DOI: 10.4254/wjh.v5.i9.462] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 07/16/2013] [Accepted: 08/16/2013] [Indexed: 02/06/2023] Open
Abstract
Nonparasitic hepatic cysts consist of a heterogeneous group of disorders, which differ in etiology, prevalence, and manifestations. With improving diagnostic techniques, hepatic cysts are becoming more common. Recent advancements in minimally invasive technology created a new Era in the management of hepatic cystic disease. Herein, the most current recommendations for management of noninfectious hepatic cysts are described, thereby discussing differential diagnosis, new therapeutic modalities and outcomes.
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21
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Gologorsky E, Carvalho EM, Macedo FI, Salerno T. An intraoperative transesophageal echocardiography-guided maneuver to assist the removal of an intraventricular thrombus. Braz J Cardiovasc Surg 2010; 24:578-80. [PMID: 20305934 DOI: 10.1590/s0102-76382009000500022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Accepted: 12/01/2009] [Indexed: 11/21/2022] Open
Abstract
Intra-cavitary thrombus size, mobility and friability are of great importance in deciding whether surgical removal is indicated. Thrombus characteristics may render surgical thrombectomy incomplete, a risk for catastrophic embolization. During de-airing of the heart, after removal of an intraventricular thrombus, filling the open ventricular cavity with blood serendipitously allowed trans-esophageal echocardiographic (TEE) visualization of undetected residual thrombi fragments. This experience leads us to advocate repeated filling and emptying of the left ventricle with blood, under TEE guidance, in order to facilitate complete removal of thrombotic material prior to ventriculotomy closure, and prior to weaning from cardiopulmonary bypass (CPB).
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Affiliation(s)
- Edward Gologorsky
- Jackson Memorial Hospital, 1611 N. W. 12th Avenue Miami, Florida, 33139, Estados Unidos, USA
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Salerno TA, Suarez M, Panos AL, Macedo FI, Alba J, Brown M, Ricci M. Resultados da abordagem transeptal para a valva mitral com coração batendo. Braz J Cardiovasc Surg 2009; 24:4-10. [DOI: 10.1590/s0102-76382009000100003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Accepted: 02/20/2009] [Indexed: 11/21/2022] Open
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